Template:Pneumonia Antibiotics: Difference between revisions
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=== | ===Outpatient=== | ||
''Coverage targeted at [[S. pneumoniae]], [[H. influenzae]]. [[M. pneumoniae]], [[C. pneumoniae]], and [[Legionella]] | ''Coverage targeted at [[S. pneumoniae]], [[H. influenzae]]. [[M. pneumoniae]], [[C. pneumoniae]], and [[Legionella]] | ||
====Healthy==== | ====Healthy<ref> Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America [https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67] </ref>==== | ||
''No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for [[MRSA]] or [[Pseudomonas aeruginosa]] (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))'' | |||
*[[Amoxicillin]] 1 g three times daily (strong recommendation, moderate quality of evidence), OR | |||
*[[Doxycycline]] 100 mg twice daily (conditional recommendation, low quality of evidence), OR | |||
*[[ | *[[Macrolide]] in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence). | ||
*[[ | **[[Azithromycin]] 500 mg on first day then 250 mg daily OR | ||
*[[ | **[[Clarithromycin]] 500 mg BID or clarithromycin ER 1,000 mg daily | ||
**[[Azithromycin]] | *Duration of therapy 5 days minimum | ||
**[[ | |||
* | |||
=== | ==== Unhealthy<ref> Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America [https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67] </ref>==== | ||
*Monotherapy or combination therapy is acceptable | ''If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa'' | ||
*The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; [[CURB-65]] ≥ 2) is associated with:<ref>Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. Aug 11, 2015</ref> | *Combination therapy: | ||
**[[Amoxicillin/Clavulanate]] | |||
***500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued<ref>IDSA. Mandell 2007</ref> | |||
**OR [[cephalosporin]] | |||
***[[Cefpodoxime]] 200 mg BID OR [[cefuroxime]] 500 mg BID | |||
**AND [[macrolide]] | |||
***[[Azithromycin]] 500 mg on first day then 250 mg daily | |||
***OR [[clarithromycin]] 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy) | |||
**OR [[doxycycline]] 100 mg BID (conditional recommendation, low quality of evidence for combination therapy) | |||
*Monotherapy: respiratory [[fluoroquinolone]] (strong recommendation, moderate quality of evidence): | |||
**[[Levofloxacin]] 750 mg daily OR | |||
**[[Moxifloxacin]] 400 mg daily OR | |||
**[[Gemifloxacin]] 320 mg daily | |||
===Inpatient=== | |||
*Monotherapy or combination therapy is acceptable | |||
*Combination therapy includes a [[cephalosporin]] and [[macrolide]] targeting atypicals and Strep Pneumonia <ref>Chokshi R, Restrepo MI, Weeratunge N, Frei CR, Anzueto A, Mortensen EM. Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Jul 2007;26(7):447-51</ref> | |||
*The use of adjunctive corticosteroids ([[methylprednisolone]] 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; [[CURB-65]] ≥ 2) is associated with:<ref>Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. Aug 11, 2015</ref> | |||
**↓ mortality (3%) | **↓ mortality (3%) | ||
**↓ need for mechanical ventilation (5%) | **↓ need for mechanical ventilation (5%) | ||
| Line 24: | Line 37: | ||
====Community Acquired (Non-ICU)==== | ====Community Acquired (Non-ICU)==== | ||
''Coverage against community acquired organisms plus [[M. catarrhalis]], [[Klebsiella]], [[S. aureus]] | ''Coverage against community acquired organisms plus [[M. catarrhalis]], [[Klebsiella]], [[S. aureus]] | ||
*[[ | *[[β-lactam]] (e.g. [[ceftriaxone]] 1–2g daily OR [[ampicillin-sulbactam]] 1.5–3g q6h OR [[cefotaxime]] 1–2g q8h OR [[ceftaroline]] 600mg q12h) '''PLUS''' | ||
*[[ | **[[Macrolide]] (e.g. [[azithromycin]] 500 mg daily or [[clarithromycin]] 500 mg BID)'''OR''' | ||
*[[ | **[[Doxycycline]] 100mg IV/PO BID (if contraindications to both macrolides and fluoroquinolones ) '''OR''' | ||
*[[Levofloxacin]] 750mg IV/PO once daily '''OR''' | |||
*[[Moxifloxacin]] 400mg IV/PO once daily | |||
==== | ====Hospital Acquired or Ventilator Associated Pneumonia==== | ||
*3-drug regimen recommended | *3-drug regimen recommended options: | ||
** | **[[Cefepime]] 1-2gm q8-12h '''OR''' [[ceftazidime]] 2gm q8h + [[Levofloxacin]] 750 mg PO/IV every 24 hours + [[Vancomycin]] 15mg/kg q12 '''OR''' | ||
**[[Imipenem]] 500mg q6hr + [[cipro]] 400mg q8hr + [[vanco]] 15mg/kg q12 OR | **[[Imipenem]] 500mg q6hr + [[cipro]] 400mg q8hr + [[vanco]] 15mg/kg q12 '''OR''' | ||
**[[Piperacillin-Tazobactam]] 4.5gm q6h + [[cipro]] 400mg q8h + [[vanco]] 15mg/kg q12 | **[[Piperacillin-Tazobactam]] 4.5gm q6h + [[cipro]] 400mg q8h + [[vanco]] 15mg/kg q12 | ||
*Consider [[tobramycin]] in place of fluoroquinolones given FDA 2016 warnings | |||
*Of note, the combination of [[vanco]]+ [[piperacillin-tazobactam]] carries higher risk of [[AKI]] when compared to [[cefepime ]]+ [[vanco]]’’’<ref> Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(1):12-20.</ref> | |||
====Ventilator Associated Pneumnoia==== | |||
*High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:<ref>Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. [http://cid.oxfordjournals.org/content/early/2016/07/06/cid.ciw353.full.pdf Clin Infect Dis. 2016 Sep 1;63(5):e61-e111.]</ref> | |||
**1. ''MRSA Antibiotic:'' [[Vancomycin]] 15mg/kg q12h OR [[Linezolid]] 600 mg IV q12h '''PLUS''' | |||
**2. ''Antipseudomonal Antibiotic:'' [[Piperacillin-Tazobactam]] 4.5gm q6h OR [[Cefepime]] 2 g IV q8h OR [[Imipenem]] 500 mg IV q6h OR [[Aztreonam]] 2 g IV q8h '''PLUS''' | |||
**3. ''GN Antibiotic With Antipseudomonal Activity:'' [[Cipro]] 400 mg IV q8h | |||
====ICU, low risk of pseudomonas==== | ====ICU, low risk of pseudomonas==== | ||
*[[Ceftriaxone]] 1gm IV | *[[Ceftriaxone]] 1gm IV + [[Azithromycin]] 500mg IV '''OR''' | ||
*[[Ceftriaxone]] 1gm IV | *[[Ceftriaxone]] 1gm IV + ([[moxifloxacin]] 400mg IV or [[levofloxacin]] 750mg IV) | ||
*Penicillin allergy | *Penicillin allergy | ||
**([[Moxifloxacin]] or [[levofloxacin]]) + ([[aztreonam]] 1-2gm IV or [[clindamycin]] 600mg IV) | **([[Moxifloxacin]] or [[levofloxacin]]) + ([[aztreonam]] 1-2gm IV or [[clindamycin]] 600mg IV) | ||
====ICU, risk of pseudomonas==== | ====ICU, risk of pseudomonas==== | ||
* [[ | * [[Cefepime]], [[Imipenem]], '''OR''' [[Piperacillin/Tazobactam]] + IV [[cipro]]/[[levo]] | ||
* [[ | * [[Cefepime]], [[imipenem]], '''OR''' [[piperacillin-tazobactam]] + [[gent]] + [[azithromycin]] | ||
* [[ | * [[Cefepime]], [[imipenem]], '''OR''' [[piperacillin-tazobactam]] + [[gent]] + [[cipro]]/[[levo]] | ||
Latest revision as of 01:20, 26 June 2020
Outpatient
Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella
Healthy[1]
No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))
- Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
- Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
- Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
- Azithromycin 500 mg on first day then 250 mg daily OR
- Clarithromycin 500 mg BID or clarithromycin ER 1,000 mg daily
- Duration of therapy 5 days minimum
Unhealthy[2]
If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa
- Combination therapy:
- Amoxicillin/Clavulanate
- 500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued[3]
- OR cephalosporin
- Cefpodoxime 200 mg BID OR cefuroxime 500 mg BID
- AND macrolide
- Azithromycin 500 mg on first day then 250 mg daily
- OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
- OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
- Amoxicillin/Clavulanate
- Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):
- Levofloxacin 750 mg daily OR
- Moxifloxacin 400 mg daily OR
- Gemifloxacin 320 mg daily
Inpatient
- Monotherapy or combination therapy is acceptable
- Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia [4]
- The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:[5]
- ↓ mortality (3%)
- ↓ need for mechanical ventilation (5%)
- ↓ length of hospital stay (1d)
Community Acquired (Non-ICU)
Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus
- β-lactam (e.g. ceftriaxone 1–2g daily OR ampicillin-sulbactam 1.5–3g q6h OR cefotaxime 1–2g q8h OR ceftaroline 600mg q12h) PLUS
- Macrolide (e.g. azithromycin 500 mg daily or clarithromycin 500 mg BID)OR
- Doxycycline 100mg IV/PO BID (if contraindications to both macrolides and fluoroquinolones ) OR
- Levofloxacin 750mg IV/PO once daily OR
- Moxifloxacin 400mg IV/PO once daily
Hospital Acquired or Ventilator Associated Pneumonia
- 3-drug regimen recommended options:
- Cefepime 1-2gm q8-12h OR ceftazidime 2gm q8h + Levofloxacin 750 mg PO/IV every 24 hours + Vancomycin 15mg/kg q12 OR
- Imipenem 500mg q6hr + cipro 400mg q8hr + vanco 15mg/kg q12 OR
- Piperacillin-Tazobactam 4.5gm q6h + cipro 400mg q8h + vanco 15mg/kg q12
- Consider tobramycin in place of fluoroquinolones given FDA 2016 warnings
- Of note, the combination of vanco+ piperacillin-tazobactam carries higher risk of AKI when compared to cefepime + vanco’’’[6]
Ventilator Associated Pneumnoia
- High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:[7]
- 1. MRSA Antibiotic: Vancomycin 15mg/kg q12h OR Linezolid 600 mg IV q12h PLUS
- 2. Antipseudomonal Antibiotic: Piperacillin-Tazobactam 4.5gm q6h OR Cefepime 2 g IV q8h OR Imipenem 500 mg IV q6h OR Aztreonam 2 g IV q8h PLUS
- 3. GN Antibiotic With Antipseudomonal Activity: Cipro 400 mg IV q8h
ICU, low risk of pseudomonas
- Ceftriaxone 1gm IV + Azithromycin 500mg IV OR
- Ceftriaxone 1gm IV + (moxifloxacin 400mg IV or levofloxacin 750mg IV)
- Penicillin allergy
- (Moxifloxacin or levofloxacin) + (aztreonam 1-2gm IV or clindamycin 600mg IV)
ICU, risk of pseudomonas
- Cefepime, Imipenem, OR Piperacillin/Tazobactam + IV cipro/levo
- Cefepime, imipenem, OR piperacillin-tazobactam + gent + azithromycin
- Cefepime, imipenem, OR piperacillin-tazobactam + gent + cipro/levo
- ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
- ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
- ↑ IDSA. Mandell 2007
- ↑ Chokshi R, Restrepo MI, Weeratunge N, Frei CR, Anzueto A, Mortensen EM. Monotherapy versus combination antibiotic therapy for patients with bacteremic Streptococcus pneumoniae community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. Jul 2007;26(7):447-51
- ↑ Siemieniuk RA, Meade MO, Alonso-Coello P, Briel M, Evaniew N, Prasad M, Alexander PE, Fei Y, Vandvik PO, Loeb M, Guyatt GH. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. Aug 11, 2015
- ↑ Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(1):12-20.
- ↑ Kalil AC, Metersky ML, Klompas M et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111.